SECTION VI - SIGNATURE SECTION A. I certify that all of the services and materials indicated above as received are indicated accurately, and authorize the release of any medical or other information necessary to process this claim. Additionally, I certify that I have been informed of all additional items and costs as outlined in Sections IV and V, and I bear the full responsibility for payment of any charge associated with any of the items selected. I understand that Progressive Addition Lenses will be furnished upon my request and if I am unable to adapt to these lenses, standard bifocal lenses will be provided with no additional cost, however, the copayment (if any) for the Progressive Addition Lenses will not be refunded. TN RESIDENTS: Please see instruction 6. Patient Signature __________________________________ Date of Service ____________________________________ B. I certify that all services were provided by me or by authorized personnel, in compliance with the standards of the Davis Vision Program.TN PROVIDERS: Please see instruction 6. Authorized Signature ______________________________ Invoice No. ______________________________________

*No copayment/additional dispense for dependent children, monocular members and patients with Rx +/-6.00 or greater.

INSTRUCTIONS: 1. Participating provider must complete Sections I, III, V, and VIB. 2. Member or legal guardian should complete and sign Section VIA 3. All services rendered should be recorded on a single form. 4. Authorization is valid for 45 days. If expired, call 1-800-773-2847 prior to rendering services. 5. Completed forms must be maintained for a period of not less than seven (7) years. 6. Tennessee state law stipulates that it is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

SR00354 11/20/06

You have specific ERISA appeals rights regarding your vision care benefits. These rights may be obtained in detail by contacting Davis Vision at 1-800-999-5431 or writing to: Quality Assurance Department P. O. Box 1525 Latham, NY 12110 Appeals must be made within 180 days of the date of service.